Showing papers in "Maryland medical journal in 1998"

Noise-induced hearing loss and symphony orchestra musicians: risk factors, effects, and management.

Abstract: Although industrial and recreational noise have been recognized as potential causes of noise-induced hearing loss for quite some time, it is only recently that the sound levels within a symphony orchestra have been implicated as possible sources of harmful noise levels. Many studies have concluded that not only are dangerous levels of noise present within the symphony orchestra, but there is evidence of noise-induced hearing loss among symphony orchestra musicians. Although hearing protection designed for industrial use may not be appropriate for the special listening needs of professional musicians, recent advances in hearing protection design have made hearing protection practical for this population. Suggestions are made for monitoring and protecting the professional ear.

Fish lesions in the Chesapeake Bay: Pfiesteria-like dinoflagellates and other etiologies.

Abstract: Ulcerative lesions and mass mortalities of Atlantic estuarine fish, particularly menhaden (Brevoortia tyrannus), have been associated with exposure to Pfiesteria-like dinoflagellates and their toxins. We collected fish from the Chicamacomico River, Maryland, and observed solitary ulcerative lesions on the majority of menhaden sampled. One striped bass (Morone saxatilis) had an area of reddening around the base of the dorsal fin. Bluegill (Lepomis machrochirus), channel catfish (Ictalurus punctatus), yellow perch (Perca flavescens), and carp (Cyprinus carpio) were externally nonremarkable. Histologically ulcerative menhaden lesions demonstrated marked chronic inflammatory infiltrate in large areas of exposed necrotic muscle. The ulcers contained granulomata with fungal hyphae in the necrotic tissue. Gram negative rod-shaped bacteria were also observed in the lesions, a common finding in ulcers of aquatic organisms. Our data suggest that typical ulcerative lesions observed on fish from areas of Pfiesteria-like dinoflagellate blooms are reflective of dermatosis, which may be related to a variety of individual or combined environmental stressors. Exposure to dinoflagellate toxin)s) potentially represents one such stressor. The role of Pfiesteria-like dinoflagellate toxin in fish primary lesion development is currently under investigation.

Antoine marfan and his syndrome : one hundred years later

Abstract: In 1896, in the Bulletin of the Medical Society of Paris, Antoine Marfan described a five-year-old girl with arachnodactyly. It took almost 50 years to fully elucidate this syndrome including aneurysm of the ascending aorta. It is critical to make an early diagnosis of Marfan aneurysm because there is a high frequency of dissection and rupture once the aortic diameter reaches 6 cm. Before the availability of the Bentall composite graft procedure in 1968, the operative results were very poor. The Bentall operation now carries a 30-day mortality rate of less than 5% at major cardiac surgical centers. Two hundred and thirty-one Marfan patients underwent aortic root replacement at The Johns Hopkins Hospital between September 1976 and December 1997. The 30-day mortality for 198 patients undergoing elective aortic root replacement was 0%. Two of 33 patients undergoing urgent surgery died in the first 30 days after surgery; both of these patients arrived in the operating room with ruptured aortas. The actuarial survival for the 231 patients undergoing aortic root replacement was 88% at five years, 81% at ten years, and 75% at 20 years. Clearly, the outlook for Marfan patients undergoing elective aortic root replacement has been excellent. Accompanying the steadily improving surgical results have been spectacular developments in understanding the genetic role in Marfan families. Since 1991, over 150 mutations have been discovered in the gene that is critical in the production of the structural protein fibrillin. The identification of mutations in the fibrillin gene has enabled the diagnosis of Marfan disease in some patients before they become symptomatic; prenatal diagnosis has been achieved in some patients. The ultimate hope for Marfan families is to eliminate the disease by genetic manipulation; however, this may be years away.

Utilization of computed tomography in patients hospitalized with community-acquired pneumonia.

Abstract: The objective of the study was to assess the frequency of the use of chest computed tomography in 385 adults hospitalized with community-acquired pneumonia and determine whether the computed tomography examinations yielded additional diagnostic information. Also, if additional information was obtained, the study determined whether it changed the patient's treatment plan.

Breathing difficulties in wind instrument players.

Abstract: Performance of a wind instrument requires appreciable lung volume and diaphragmatic mechanical force, skilled breath control, adequate patency and humidity of air passages, and precise coordination of the oropharyngeal cavity. Depending on the instrument class, variable rates of air flow, pressure, and duration are necessary to produce optimal tone quality. Wind players may be seriously impaired by respiratory diseases that, comparatively, might appear trivial to the nonperformer. The workplace environment should be assessed for occupational hazards when managing these patients, and smoking should be particularly discouraged. Controversy exists implicating wind instrument use in the exacerbation of respiratory disease, including bronchial, laryngeal, pharyngeal, and oral anatomic changes--a result of the constant barotrauma of performance. Asthma is the most common chronic pulmonary disorder among wind players, and therapeutic programs that include breath training and physical exercise improve symptoms, endurance, and general well-being.

Neurobehavioral complaints of symptomatic persons exposed to Pfiesteria piscicida or morphologically related organisms.

Abstract: Over the next year, additional persons in Maryland may be at risk for exposure of toxic Pfiesteria or morphologically related organisms. These persons may present with a variety of memory and other behavioral complaints. This paper examines the kinds of complaints that persons with a documented Pfiesteria-related syndrome have compared to a nonexposed control group. The exposed group was more likely to report difficulties with concentration, forgetfulness, prospective memory, and information overload as well as feelings of confusion, bewilderment, and uncertainty as direct effects of toxin exposure. The exposed group was also more likely to report feeling uneasy, on edge, nervous, and shaky, which is probably a reaction to their newly acquired cognitive deficits and uncertainty about their recovery. In contrast, retrograde memory loss, disturbances of language or social behavior, depression, anger, hostility, or diminished activity levels are not symptoms that exposed persons are likely to report.

Pfiesteria in Maryland: preliminary epidemiologic findings.

Abstract: In the fall of 1996, fish kills in Maryland rivers were attributed to the dinoflagellate, Pfiesteria piscicida. After a group of researchers established a potential link between exposure to Pfiesteria and an illness causing memory problems, state health authorities closed a portion of the Pocomoke River. To determine the extent of illness, the range of symptoms, potential risk factors for disease, and to provide information to concerned citizens, a toll-free hotline was created. All symptomatic persons who called the toll-free number were administered a standardized questionnaire. Persons who had been exposed to Pfiesteria or Pfiesteria-laden waters were more likely to have respiratory, neurologic, dermatologic, and gastrointestinal problems than those persons without exposure. Among the persons calling the hotline, many had extensive neuropsychologic testing. Of the neuropsychologic test battery, low scores on the Rey Auditory Verbal Learning Test (RAVLT), a standardized measure of learning and memory, best characterized illness related to Pfiesteria exposure. Patients with low RAVLT scores were more likely to have neurologic symptoms and skin lesions than control subjects. Low RAVLT scores were associated with fishing (OR, 9.00, 95% CI, 106, 409.87), catching fish with lesions (OR, 6.17, 95% CI 1.27, 32.10), and handling fish with lesions (OR, 5.34, 95% CI, 1.05, 29.92), but not with consumption of seafood. While preliminary, these results do suggest that some risk factors for Pfiesteria-related illness may be easy to modify and used to prevent unnecessary human exposure.

Treatment of persistent Pfiesteria-human illness syndrome.

Abstract: Patients with exposure to Pfiesteria toxin have developed an illness, Pfiesteria-human illness syndrome, characterized by skin lesions, headache, myalgias, conjunctival irritation, bronchospasm, abdominal pain, secretory diarrhea, recent memory loss, and difficulties with number sequencing. Not all patients demonstrated all features of the syndrome. The natural history of Pfiesteria-human illness syndrome shows that most patients' symptoms improve without treatment. This article reports the improvement of symptoms that had persisted for over one month in five patients, which the author attributes to treatment with cholestyramine. These patients were self-referred to the Pocomoke River Rash and Associated Illness Center, a clinic that opened on August 6, 1997, in response to the need for a central facility for diagnosis of human illness acquired from Pfiesteria. Until the Pfiesteria toxin(s) is isolated and characterized, and laboratory diagnostic tests are available, physicians must be able to recognize Pfiesteria-human illness syndrome and intervene when symptoms, particularly memory loss and diarrhea, cause significant impairment in daily activities. There are no precedents for the treatment of Pfiesteria or any dinoflagellate toxin-related human illness reported in the literature. The successful use of cholestyramine reported here may provide a model for understanding dinoflagellate toxin physiology in the human body. This paper reports an uncontrolled observational study. When identification of the toxin is completed, a basis for properly controlled studies will be available.

Neurologic symptoms following Pfiesteria exposure: case report and literature review.

Abstract: Although the recently identified dinoflagellate, Pfiesteria piscicida, may have neurotoxic effects on humans, the precise nature of the neurologic symptoms associated with varying levels of exposure is unknown. Toward this end, we review the neurologic symptoms of three Pfiesteria-exposed laboratory workers reported to data and compare them to the evaluation of an exposed waterman from Maryland. The occupational exposure of a Maryland waterman appears to produce a mild, reversible encephalopathy which predominantly affects functions associated with the frontal and temporal lobes. A comprehensive neurologic examination is recommended for all Pfiesteria piscicida and morphologically related organism-exposed, symptomatic persons.

Surgical education via the Internet: the Cardiothoracic Surgery Network.

Abstract: The Cardiothoracic Surgery Network is an international collaborative effort among cardiothoracic surgeons that provides a common platform for the exchange of information. The Cardiothoracic Surgery Network website provides peer-reviewed journals, multimedia applications, and a database repository.

Strategies for environmental monitoring of toxin producing phantom dinoflagellates in the Chesapeake.

Abstract: Toxin-producing estuarine dinoflagellates have been linked with the occurrence of fish kills and the development of a novel clinical illness syndrome among persons exposed to waters during fish kill events. The prototype organism of this group, Pfiesteria piscicida, has an extremely complex life cycle, making traditional methods used for environmental monitoring of harmful algal blooms less reliable. The response to fish kill events and the occurrence of human illness in Maryland in 1997 is reviewed, with particular emphasis on problems in organism detection. Current and anticipated classical and molecular methodologies for the detection of Pfiesteria and Pfiesteria-like organisms are reviewed. Development of these capabilities will be of critical importance in defining the epidemiology of human illness related to environmental exposure to Pfiesteria, and in developing public health strategies to predict and prevent such illness.

A critical review of the Pfiesteria hysteria hypothesis.

Abstract: Mass hysteria or mass psychogenic illness is the spread of the belief of an illness (symptoms and the origins of the symptoms) through a population. The characteristics of mass psychogenic illness were reviewed and compared to the recent outbreak of human illness in the Pocomoke region in Maryland in the summer of 1997. The findings suggest that the nature of the symptoms complex--the onset and recovery course; the absence of secondary gain or job-related stress for most of the symptomatic persons; the predominance of males in the symptomatic group; and the baseline emotional stability of all persons examined--are inconsistent with the reported features of psychogenic illness in response to unknown environmental or chemical toxins. Although there may be individuals who exhibited hypochondriacal, hysterical, or other functionally based reactions, the recent outbreak of Pfiesteria-related illness probably does not represent an episode of mass psychogenic illness.

Pfiesteria and the skin: a practical update for the clinician.

Abstract: Skin complaints, including an episodic burning sensation on contact with river water, were common among 13 persons with exposure to Maryland's Pocomoke River in the summer of 1997. While the majority of findings on dermatologic examination were unrelated to toxic dinoflagellate exposure, a subset of patients demonstrated otherwise unexplained erythematous, edematous papules on the trunk or extremities. Histopathologic findings were suggestive of an inflammatory, toxic, or allergic process. It may be speculated that these otherwise unexplained cutaneous findings represent a cutaneous reaction to Pfiesteria or Pfiesteria-like toxin; however, further evaluation of future affected persons will be warranted.

Toxic pfiesteria : surveillance for human disease in maryland

Abstract: The presence of toxic stages of the dinoflagellate Pfiesteria piscicida and other morphologically related organisms was documented in three estuarine waterways on the lower Eastern Shore of Maryland in 1997. The Maryland Department of Health and Mental Hygiene, working closely with the local health departments, established a surveillance system to collect reports of human illnesses. Maryland's experience has formed the base on which national surveillance criteria for Estuary Associated Syndrome have been developed and regional surveillance protocols have been built. The cooperation of practicing physicians is essential to continued surveillance efforts to further delineate the extent and nature of human health effects following exposures to waters where toxic forms of these dinoflagellates are active. Physicians wishing to report persons who may have Estuary Associated Syndrome should contact their local health department. Persons wanting information or wishing to report finding lesioned fish or a fish kill in progress should call the Maryland Pfiesteria Hotline at 1- 888-584-3110.

Psychologic adjustment of watermen with exposure of Pfiesteria piscicida.

Abstract: Preliminary study of the psychologic adjustment of watermen with exposure to Pfiesteria piscicida was conducted on watermen with the most severe exposures and their occupationally matched controls. Participants in the exposed group were seven symptomatic recreational and commercial fishermen who had direct exposure to the Pocomoke River or other estuarial waters on Maryland's Eastern Shore before, during, and/or after periods of documented fish kills and Pfiesteria activity. The control group included eight commercial fishermen who worked on the ocean side of the Eastern Shore and had no reported exposure to estuaries with documented Pfiesteria activity. Both exposed symptomatic and nonexposed watermen completed the Profile of Mood States to assess depression, anxiety, and other relevant mood states as part of their participation in the larger investigation of the human health effects of Pfiesteria piscicida. Preliminary results suggest that both exposed symptomatic and nonexposed watermen are psychologically healthy and exhibit what psychologists refer to as the classic Iceberg Mood Profile. The Iceberg Profile is characterized by endorsement of symptoms suggestive of high energy, enthusiasm and positive mood (e.g., lively, active, energetic, cheerful, vigorous, etc.) and relative minimization of symptoms suggestive of negative or depressed mood (e.g., tense, anxious, restless, grouchy, forgetful). Therefore, the Pfiesteria-related symptom complex documented in the exposed watermen cannot be explained by functional or psychiatric factors and is probably due to exposure.

Flush resuscitation for group A streptococcus toxic shock: a possible role for continuous renal replacement therapy and plasmapheresis.

Abstract: Group A streptococcus has emerged as a major cause of aggressive life-threatening deep-seated infections. In addition, toxic shock syndrome caused by Group A streptococcus was recognized in 1983. Group A streptococcus produces several potent exotoxins which explain the pathophysiology of these invasive infections. Other virulence factors such as M protein, which can impede phagocytosis, are associated with some Group A streptococcus. M protein and streptococcal pyrogenic exotoxins may act as super antigens. Host factors may influence the severity of infection. Blood purification techniques such as continuous renal replacement therapy and plasmapheresis can remove streptococcal exotoxins as well as inflammatory mediators. Replacement with fresh-frozen plasma corrects coagulopathy and may provide some antibody protection. Four patients with Group A streptococcus-toxic shock syndrome treated with continuous renal replacement therapy, plasmapheresis, or both showed dramatic, rapid improvement in cardiovascular dynamics and respiratory parameters. Two patients died. The mainstay of treatment for Group A streptococcus-toxic shock syndrome remains early diagnosis, aggressive surgical control of the infection, and appropriate antibiotics (i.e., penicillin and clindamycin). Flush resuscitation may rescue some patients from profound toxic shock. The mechanisms of action need to be delineated.

Hoarseness--current concepts on etiologies and treatment alternatives.

Abstract: The care of the human voice has challenged medical practitioners for centuries. Over the last 25 years we have seen significant advancements in the diagnosis and treatment of vocal disorders. This article is an overview of the more common voice disorders encountered in clinical practice and the diagnostic and management alternatives currently available. A thorough understanding of these conditions can lead to a prompt diagnosis and improved clinical outcomes in all patients, especially professional voice users. The insights presented are compiled through the eyes of a clinician and the heart of a performer.

Advance directives in internal medicine outpatient residents' clinics.

Abstract: This study assessed the frequency of obtaining advance directives from patients of internal medicine residents in two Baltimore teaching programs. A survey was conducted of the medical records of 130 patients in the medical clinics from these programs. Independent variables included age, sex, and race. Dependent variables included documentation of terminal illnesses, resuscitation or code status, and discussion regarding resuscitation status. Only 25 of 130 patients (19%) had a resuscitation status recorded, 24 were documented as full resuscitation and 1 as do not resuscitate. Of subjects older than 65 years, 23% had a resuscitation status. Although 4 of 37 subjects older than 65 years had a terminal illness, none had advance directives.

Gastric cancer: an overview with emphasis on early gastric cancer.

Abstract: Gastric cancer has the second highest mortality rate of all cancers worldwide. More attention is now being paid to the symptoms and risk factors involved. There is also increasing use of esophagastroduodenoscopy and random biopsies in symptomatic patients, especially as a screening mechanism in Japan. As a result, lesions are being diagnosed earlier.

Endobronchial stents: primary and adjuvant therapy for endobronchial airway obstruction.

Abstract: Endoscopic management of symptomatic tracheobronchial airway stenosis can be an important adjunct to the care of patients with malignant, benign, and lung transplantation airway complications. For most of these patients, endobronchial dilation, debridement, and/or stenting offer significant palliation and improved quality of life. The underlying etiology of the stenosis is critical in directing the most effective and safe endobronchial therapy. The use of stents in both malignant disease and lung transplantation may offer considerable symptomatic relief with minimal complications. However, the use of stents in benign disease should be reserved for inoperable patients with no other therapeutic options.

Treatment of congestive heart failure with beta-adrenergic blockers: a brief review of literature.

Abstract: The importance of the adrenergic nervous system in support of hemodynamics in patients with congestive heart failure has been known for a long time. Thus, when beneficial effects of beta-blocker therapy in patients with resistant congestive heart failure were reported more than two decades ago, such an approach was deemed counterintuitive. Despite the skepticism, numerous reports, including well-planned, randomized studies, confirmed the beneficial effects of various beta-blockers on congestive heart failure. Recently, a new generation of beta-blocker, carvedilol (Coreg), which combines nonselective beta-blocking and vasodilating properties, was cleared by the U.S. Food and Drug Administration for the treatment of congestive heart failure. This article is a brief historical review of the literature regarding the use of beta-blockers for the treatment of congestive heart failure.

Thoracic transplantation in 1998.

Abstract: Thoracic transplantation has been a clinical option for patients with end-stage heart and lung disease for three decades. Heart, lung, and combined heart-lung transplantations are no longer experimental procedures; they are a standard part of the treatment algorithm for selected patients with end-stage heart and lung disease. This article summarizes the current status of heart, lung, and heart-lung transplantations and provides an insight into the future of this field.

Performing arts medicine and the internet

Abstract: The tremendous growth of the Internet and the World Wide Web over the last ten years has revolutionized communication in the United States A great deal of information is available to assist in patient education and medical decision making The field of performing arts medicine represents only a small portion of the web, but the relevant sites provide much helpful material Bibliographic sites lead the researcher to further print resources Many of the organizations concerned with performing arts medicine have web sites describing their history, goals, and services Sites maintained by individuals, universities, and associations cover the field in general, as well as specific topics such as repetitive strain injuries, related computer and typing injuries, carpal tunnel syndrome, and hearing loss Performing arts medicine is a highly interdisciplinary field and the collaborative nature of the Internet is well suited to this diverse, geographically dispersed population